A PPT on the traumatic paraplegia

2. TRAUMATIC PARAPLEGIA
MODERATORS:
DR.T.M.RAVINATH sir
DR.B.SUBODH SHETTY sir
Presented by Dr.G.SRI HARSHA

3. INTRODUCTION
• Spinal Cord Injury is an insult to the spinal cord
resulting in a change either temporary or permanent
in the cord’s motor,sensory,or autonomic function.
• The International Standards for
Neurological and functional Classification
of Spinal Cord Injury(ISNCSCI)is a widely
accepted system of describing the level and extent of
injury which gave the following terminologies.
• Tetraplegia-injury to the spinal cord in the
cervical region with associated loss of muscle
strength in all 4 extremities.
• Paraplegia-Injury to the spinal cord in the
thoracic,lumbar or sacral segments including the
cauda equina and conus medullaris.

4. Neural injuries are divided into two broad etiology
based categories.
• Primary Injury-Physical tissue disruption
caused by mechanical forces.
• Secondary Injury-Additional neural tissue
injury resulting from the biologic response initiated
by the physical tissue disruption.
Classification based on the physical Characteristics.
• Concussion-physiologic disruption without
anatomic injury.
• Contusion(most common)-physical tissue
disruption leading to hemorrhage and swelling.
• Laceration(very rare)-loss of physical continuity
i.e, complete transection of neural tissue.

5. • Spinal cord injury predominantly occurs in the
young males,with a male to female ratio of 4:1.
• The most common cause of traumatic spinal
cord injury is a motor vehicle crash-42%.
• Falls-27%
• Gunshot injuries-16%.
• Sports injuries-7%.

6. • The most common site of spinal cord injury is
the cervical spine-50-64%,
• Followed by lumbar region-20-24% and
• Thoracic cord-17 to 19%.

7. Brief Anatomy of the Spinal Cord
• The spinal cord is divided into 31 segments,each with a pair of
anterior and posterior spinal nerve roots.
• On each side the anterior and dorsal nerve roots combine to form the
spinal nerve as it exits from the vertebral column through the neural
foramina.
• The spinal cord extends from the base of the skull to the lower end of
the L1 vertebral body.
• The spinal cord is organized into a series of tracts or neuropathways
that carry motor and sensory information.
• The corticospinal tracts are descending motor pathways which
decussate in the medulla located anteriorly within the spinal cord.
• The dorsal columns are the ascending sensory tracts that transmit
light touch,proprioception,and vibration information to the sensory
cortex.
• The lateral spinothalamic tracts transmit pain and temperature
sensation.
• Sympathetic (thoraco lumbar outflow)exits between the C7 to L1.
• Parasympathetic pathways(Craniosacral outflow) exit between the
S2-S4 segments.

9. • Cervical vertebra-Add 1
to the vertebral level.
• Upper thoracic
vertebrae-Add 2.
• Lower thoracic(T7-T9)-
Add 3.
• At D10-L1 & L2.
• At D11-L3 & L4.
• At D12-L5 cord segment.
• At L1-All Sacral
segments over.
• Below L1-Cauda Equina.

10. Vascular supply
• It consists of the one anterior and two posterior
spinal arteries.
• The anterior spinal artery supplies the anterior two
thirds of the spinal cord.
• It arises from the union of two arteries arising from
the vertebral artery.
• Posterior spinal artery,two in no. and arises directly
from the terminal branch of each vertebral
artery(posterior inferior cerebellar artery).
• The anterior and posterior arteries are
supplemented by the radicular arteries,the largest of
these is the artery of Adamkiewicz which usually lies
on the left side and reinforces the arterial blood
supply to the lower end of the spinal cord.

11. Spinal Cord Injuries Proper
• Complete injury of the spinal cord is defined by the
absence of the sensory and motor function in the lowest
sacral segment.
• Sacral sensation refers to the sensation at the anal
mucocutaneous junction and deep anal sensation.
• Sacral motor function is voluntary anal sphincter
contraction on digital examination.
• Incomplete injury have partial preservation of the
sensory or motor in the lower sacral segment.
• For the patient to be sensory incomplete they must
demonstrate either sensory preservation in the S4-S5 or
deep anal sensation.
• For the patient to be motor incomplete they must
demonstrate either voluntary anal sphinchter contraction
or presence of lower extremity motor function more than
three levels below the designated motor level of injury.

12. Initial assessment and care-
• All trauma patients are at risk for spinal injury.
• Proper extrication of the patient and
immobilization of the spine are critical to avoid
further neurological injury.
• Immobilizing the patient in a Kendricks
Extrication device is an effective means in
spinal emergencies.
• Other options for immobilization include hard
cervical collar,sandbags,spine board.

15. Logrolling of the patients is an important maneuver in the field transportation
of the patients

16. Emergency room care-
Differences between the neurogenic and
hemorrhagic shock should be identified

17. • The American Spinal Injury Association(ASIA)
provides a useful format for guiding in the
assessment of the neurological injury.

19. • The essential elements in the examination in the
neurologic function include strength assessment of the
5 specific muscles in each limb and pinprick sensation
testing at 28 specific points on each side of the body.
• On each side of the body five muscles representing the
segments of the lumbar cord are score on a 5-point
muscle grading scale.The sum of all 20 muscles yields
a total score for each patient with a maximum possible
score of 100.

23. • For the 28 sensory dermatomes on each side of
the body sensory levels are scored on a 0-2 scale
with a total score of 112.

26. Spinal shock
It was first defined by Whytt in 1750 as a loss of
sensation accompanied by motor paralysis with
initial loss but gradual recovery of reflexes,
following a spinal cord injury (SCI).
Reflexes in the spinal cord caudal to the SCI are
depressed (hyporeflexia) or absent (areflexia)
while those rostral to the SCI remain unaffected.
It should be distinguished from the neurogenic
shock which is characterized by the hypotension
and loss of reflexes below the spinal level of
injury.

30. Bladder in Paraplegia
UMN Bladder or Automatic Bladder
or Spastic Bladder.
• Lesion cranial to the S1-S3.
• Detrusor Sphincter Dysynergia.
• Partial voiding(intact local reflex
arc).
• Residual volume.
• Difficulty to express.
• Loss of voluntary control.
LMN Bladder or Aitinomous
Bladder or Flaccid Bladder.
• Lesion interupting the reflex
arc(S1-S3).
• Partial emptying of the
bladder.
• Residual volume larger than
the UMN bladder.
• Easy to manually express.
• Loss of voluntary control.

33. Diagnostic Modalities.
• 1.Plain Xray-AP and Lateral views of the TL
and LS spine should be obtained.

34. Points to be noted in AP View.
• Isolated fractures of the transverse
process.
• Loss of vertebral height.
• Widening of the interpedicular
distance.
• Vertebral translation.
• Increased interspinous distance.
• Horizontal split in the body at the
level of pedicles.

35. Points to be noted in lateral view
• Loss of anterior vertebral body
height.
• Kyphosis.
• Spinous process widening.
• Loss of posterior vertebral body
height.
• Translation.
• Spinous process fracture.

36. 2.CT Scan.
Advantages:
• Most accurately depicts bony
injuries.
• Sensitivity and specificity > 95% .
• Concomitant multi-slice CT of
chest, abdomen and pelvis can be
done to detect visceral injuries.
• Extent of vertebral body
comminution.
• Retropulsion of bone
fragments.
• Lamina fracture.
• Pedicle fracture.

38. Reverse Cortical sign
• The retropulsed fragment that has rotated
more than 180 degrees so that the cortical
surface is opposed to the cancellous
surface of the main vertebral body.
• Severe disruption of the posterior
ligamentous complex
• Due to 180° rotation the fragment will not
unite with the main vertebral body
• Anterior decompression is usually
preferred.
• Contraindication for ligamentotaxis.

39. 3.MRI-
Indications:
• Patients with neurological deficit.
• Patients with suspicious PLC injury.
Advantages:
• In patients with neurological deficit, MRI accurately
depicts the extent of cord compression, edema,
hemorrhage and the presence of cord transection.
• Determines extent of injury to posterior ligamentous
complex. .
• Helps to identify multi-level non-
contiguous injuries.
Disadvantages:
• Cost and availability.
• Delay in definitive management.

40. • Bony compression of spinal
cord.
• Hyperintense signal changes
in cord.
• Hyperintense signal in the
PLC.
• Marrow edema in adjacent
bones.
• Epidural hematoma.
• Cord transection.
• Multilevel injury.

41. Role of Steroids in the Acute Spinal
Cord Injuries

42. • Methylprednisolone is not recommended for the
following circumstances.
• The multiply injured patient.
• Penetrating spinal cord injury.
• Patients with glucose intolerance or diabetes
mellitus.
• Patients with multiple medical comorbidities or
with impaired immune system.
• Elderly patients.
• Patients with a complete thoracic spinal cord
injury

43. Thoracolumbar Injuries in Brief

44. Denis three column concept of
stability.

45. McAfee’s Classification of fractures of
Thoracolumbar spine
• 1.Wedge Compression
Fractures-isolated failure of the
anterior column and result from
forward flexion.
• 2.Stable Burst Fractures-anterior
and middle columns fail and there is
no loss of integrity of the posterior
elements.
• 3.Unstable Burst Fractures-All
the three columns are disrupted.There
is a tendency for the posttraumatic
kyposis.

46. • 4.Chance fractures-Horizontal avulsion
injuries of the vertebral bodies caused by
flexion around an axis anterior to the ALL.The
entire vertebra is pulled off by the tensile force.
• 5.Flexion Compression Fractures-Flexion
occurs at an axis posterior to the ALL.The
anterior column fails in compression whereas
the middle and the posterior columns fail in
tension.
• 6.Translational Injuries-these are
characterized by the malalignment of the
neural canal which has been totally
disrupted.all the three columns fail in shear.

48. Management of Thoracolumbar
injuries
• Stable injuries of the spine can be managed with
braces.

49. • The operative decision making is dictated by the
• -Morphology of the fracture.
• -The status of PLC.
• -Neurologic status of the patient.
• -Other medical comorbidities

50. Indirect Decompression
• The indirect approach to decompress the spinal
cord by ligamentotaxis is a technique that
utilizes the posterior instrumentation and a
distraction force applied to the intact posterior
longitudinal ligament to reduce the retropulsed
bone fragments from the spinal canal by
tensioning the posterior longitudinal ligament.

51. • Ligamentotaxis.

52. Direct Decompression
1.Posterior Approach-
• This is one of the most commonly used approach
for the thoracolumbar injuries.
• Advantages are it reduces the morbidity
associated with the anterior approach like
decreasing the operative blood loss,avoids
visceral injury.decreases the operative time.
• Transpedicular screw fixation is the gold
standard approach now for the treatment of
thoracolumbar injuries.

54. 2.Closed Reduction
• Primary reduction is performed
by positioning of the patient onto
a frame to create lordosis.
3.Pedicle screws.
• Pedicle screws are inserted into
the vertebrae cephalad and caudal
to the fracture level on both sides.
4.Rod contouring
• The contouring of the rod
depends on the site of the fracture
following the natural curvature of
the spine.

55. 5.Rod insertion
• The rods are introduced to the distal
screw heads on both sides and
tightened.
• The rod is then inserted into the
proximal screw heads without
tightening.
6.Decompression
• If it is decided to perform an indirect
decompression, this is done at this
stage. If indirect decompression
proves to be insufficient, a direct
decompression eg, posterior or
transpedicular decompression are
undertaken.

57. 2.Anterior approach-
• The indications include:
• The presence of a traumatic disc herniation causing
neurologic injury.
• The need to remove a portion or entire vertebral
body followed by reconstruction for stability, or for
relief of symptomatic neural compression
• Ventral epidural hematoma.
• Kyphotic angulation with ventral compression.
• An anterior decompression can be done through a
partial or total corpectomy, both including
discectomies above and below the fractured
vertebra.
• If a vertebral body or a disc lesion compresses the
spinal cord, it should be removed with the respective
decompression technique.

59. Step 1: Discectomy
• Discectomy always precedes corpectomy, because it
allows the surgeon to visualize the upper and lower
limit of the spinal canal.
• For partial corpectomy, discectomy is done for the
disc adjacent to the fractured end plate.
• For a complete corpectomy, discectomy is done
both above and below that fractured vertebra.

61. Step 2 - Corpectomy
• In a second surgical step, a total or a partial
corpectomy is undertaken.
• A total corpectomy involves removal of the
entire vertebral body and adjacent discs.
• Partial corpectomy involves removal of fractured
ends of vertebral body and adjacent discs.

62. Step 3- Reconstruction.
1.Total corpectomy
• Anterior reconstruction of
the disc space or vertebral
body following a complete
corpectomy can be
performed using an
autograft or allograft, strut
graft, or a synthetic or
metallic cage (expandable
or non expandable).
• Additional bone grafting
can be used from the
corpectomized vertebral
body and the removed rib.

63. 2.Partial corpectomy
• The anterior reconstruction
of the vertebral body is
performed using a mesh or
tricortical iliac crest bone
graft.
• The bone graft stemming
from the vertebral body is
transplanted to bridge the
segment

64. 4 Stabilization
Application of plate
instrumentation
• The appropriate size plate
is chosen by using a
measuring forceps to
determine plate length.
• A plating template is then
applied to the remaining
vertebral bodies to make
sure the plate fits flush on
the bone.
• A drill guide is used to drill
holes within the vertebral
body.

65. • Anterior rod screw system
• Another form of anterior instrumentation is using a
single rod construct after placing a strut graft with a
bone screw above and below the fusion site. Some
fixation systems are designed to place two rods in
parallel to one another to provide the potential for
standalone anterior fixation.

66. Rehabilitation in spinal cord injuries.
• Rehabilitation following SCI is most effectively
undertaken with a multidisciplinary, team-based
approach, as follows.
• Physical therapists.
• Occupational therapists.
• Rehabilitation nurses.
• Psychologists.

67. 1.Pressure ulceration(Bed Sores).
Stage I: Non-blanchable erythema.
Stage II: Partial thickness.
Stage III: Full thickness skin loss.
Stage IV: Full thickness tissue loss.

68. 2.Spasticity:
• It is a velocity-dependent increase in muscle
tone and occurs commonly following spinal cord
injury.
• Regular muscle stretching and joint range of
motion prevents this.
• Oral medication include Baclofen 200mg tid.

69. 3.Thromboembolic disease
• The increased risk of thromboembolism is likely
due to venous stasis and hypercoagulability.
• Pneumatic compression devices can be used for
the first 2 weeks. Unfractionated heparin (5000 U
SC every 12 hours) or a low-molecular-weight
heparin (30 mg SC every 12 hours), such as
enoxaparin, can be administered for 2-3 months
following injury.

70. 4.Bladder management:
• Acute bladder management is by use of an indwelling
catheter, as the bladder is likely to be flaccid.
• Selection of a bladder drainage method ideally is made
following urodynamic evaluation. Clean intermittent
catheterization is a method available to those with good
hand function or to skilled attendants. The patient is
instructed to limit fluid intake, and catheterization is
performed every 4-6 hours.
• Reflex voiding into a condom catheter is an option
available to men with reflex bladder contractions.
Problems can include urinary retention or high
intravesical voiding pressure due to detrusor-sphincter
dyssynergy. Voiding pressure sometimes can be decreased
by alpha-blocking agents such as terazosin or tamsulosin .

71. 5.Bowel Management.
• A typical problem is stool that is too hard
because of the prolonged colonic transport time,
which leads to drying of the stool.
• Intervention includes maintenance of adequate
intake of fluid and fiber, with fiber acting as a
sponge to hold moisture within the stool.
Docusate sodium (100 mg PO bid) can increase
the ease with which water enters the stool.
• Another problem is incontinence. The goal is to
establish a set time for daily bowel evacuation,
ideally after a meal to take advantage of any
gastrocolic reflex.

72. 5.Neuropathic Pain.
• Neuropathic pain following spinal cord injury (SCI)
is perceived at or below the level of injury.
• Anticonvulsants may be particularly useful in cases of
lancinating electrical pain. Gabapentin (initial dose of
100 mg PO tid, gradually titrated upward) typically is
used, with precautions for sedation.
• Tricyclic antidepressants like amitryptiline may be
useful for more constant diffuse pain.

73. 6.Functional Rehabilitation:
With regard to recovery below the level of the
lesion, ASIA A patients typically do not show
significant recovery in this area. Individuals who
are in ASIA B have approximately a 31% chance
of improving to grade D at 1-year follow-up,
while those with initial grades of C have a 67%
likelihood.